Free to breathe

February 5, 2018

Should e-cigarettes be provided free to smokers who cannot or will not quit, asks Neil McKeganey.

While smoking rates have steadily declined in recent years, there are still around 9m people smoking in the UK and approximately 120,000 smoking-related deaths per year. Although tobacco control has been one of the highlights of global public health, the challenge of further reducing smoking prevalence becomes harder, not easier, over time.

Those smoking now are doing so in the face of the known harms of smoking, decades of smoking bans, graphic health warnings, tax hikes on tobacco products, age restrictions on the sale of tobacco products, advertising bans and widespread social opprobrium directed towards smokers. If the UK is going to succeed in further reducing smoking prevalence it is going to have to do something radically different to what it has done in the past. One thing the government might now consider is providing smokers with free access to e-cigarettes.

E-cigarettes have been characterised by Public Health England as at least 95 per cent less harmful than conventional cigarettes. We know from research in the US that smokers using e-cigarettes are more likely to have attempted to quit, and that those quit attempts are more likely to have been successful. There is also growing evidence that providing smokers with access to e-cigarettes has a beneficial impact, even if those smokers have not previously committed to quitting. Recent research from the University of South Carolina, for example, found that nearly a third of smokers provided e-cigarettes for free had reduced their smoking by at least 50 per cent over the three-month period the researchers were monitoring them.

Nobody is suggesting that e-cigarettes are harmless, but if they are much less harmful than the alternative and can have a beneficial impact – even for smokers not already determined to quit – why aren’t we doing all we can to reduce the barriers to vaping? Charging smokers a price for using e-cigarettes is one of the barriers that is starting to look decidedly inappropriate.

There is an inverse relationship between smoking and deprivation, with the highest levels of smoking, and the highest levels of smoking-related harm, found in the poorest communities. There is probably nothing that would have a greater impact on reducing health in­equalities than reducing smoking among the poorest sectors of society. On that basis it makes no sense to attach a financial barrier to smokers’ access to e-cigarettes – especially where that barrier is going to be greater in the communities where levels of smoking are at their highest.

Providing free e-cigarettes to smokers who cannot quit, or who will not quit, may be the equivalent of investing millions in flu vaccinations or providing statins to those at risk of future health problems. These are programmes that are funded in the expectation of future savings. There are few savings greater than those that can be achieved by reducing smoker numbers. The cost of providing smokers with free access to e-cigarettes may be a cost that is easily justifiable if it results in a further reduction in smoking prevalence.